[% # INCLUDE dumper.tt dump = pds %]
[% # INCLUDE dumper.tt dump = params %]
[% # INCLUDE dumper.tt dump = errs %]
<div class="container">
<div class="row">
<a name="top">
<img src="[% request.uri_base %]/images/logo.jpg" title="LCC Logo"
border="0" align="right" alt="LCC Logo"/>
</a>
</div>
<div class="row">
<form class="form-horizontal" action="/" method="post">
<!-- Form Name -->
<legend>HMDS Request Form</legend>
<h4><a href="#" id="is_trial">Request IS for clinical trial</a></h4>
<div id="trial-content" style="display: none;">
<p class="text-warning indent">
Please use specific clinical trial request form.
</p>
</div>
<h4><a href="#" id="non_trial">Request is NOT for clinical trial</a></h4>
[% IF errs %]
<p class="dfv-err">Form validation failed, please correct error(s) below:</p>
[% ELSIF pds.size; PROCESS pds.tt; END %]
[% IF params.item('_skip_pds') || is_validated; # latter set in pds.tt if SMSP-0000
generate_pdf = 1; # flag for submit button control %]
<input type="hidden" name="generate_pdf" value="1" />
<div class="row indent">
<p class="bg-success col-md-6">Form passed validation. Please check
details are correct and re-submit. Then print the request form
with barcode and send with your specimen(s) to the laboratory at
the address provided.</p>
</div>
[% END %]
<div id="non-trial-content" class="indent" [% # auto-open if form submission:
UNLESS params.size %]style="display: none"[% END %]>
<fieldset>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="last_name">Last name</label>
<div class="col-md-4">
[% errs.last_name %]
<input id="last_name" name="last_name" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.last_name %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="first_name">Forename(s)</label>
<div class="col-md-4">
[% errs.first_name %]
<input id="first_name" name="first_name" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.first_name %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="textinput">Date of Birth</label>
<div class="col-md-4">
[% errs.day OR errs.month OR errs.year %]
[% INCLUDE dateselect.tt %]
</div>
</div>
<!-- Multiple Radios (inline) -->
<div class="form-group">
<label class="col-md-2 control-label" for="radios">Gender</label>
<div class="col-md-2">
[% errs.gender %]
<label class="radio-inline" for="gender-0">
<input name="gender" id="gender-0" value="M" type="radio"
[% 'checked' IF params.gender.match('M') %]>M
</label>
<label class="radio-inline" for="gender-1">
<input name="gender" id="gender-1" value="F" type="radio"
[% 'checked' IF params.gender.match('F') %]>F
</label>
<label class="radio-inline" for="gender-2">
<input name="gender" id="gender-2" value="U" type="radio"
[% 'checked' IF params.gender.match('U') %]>U
</label>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="nhs_number">NHS number</label>
<div class="col-md-4">
[% errs.nhs_number %]
<div id="nhsno_result" class="dfv-err"></div>
<input id="nhs_number" name="nhs_number" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.nhs_number %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="patient_number">
Patient/unit number
</label>
<div class="col-md-4">
[% errs.patient_number %]
<input id="patient_number" name="patient_number" type="text"
placeholder="optional field" class="form-control input-md"
value="[% params.patient_number %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="location">
Referring hospital
</label>
<div class="col-md-4">
[% errs.location %]
<input id="location" name="location_name" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.location_name %]">
<input type="hidden" id="location_id" name="location_id"
value="[% params.location_id # in case resubmitted %]" />
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="referrer">Consultant</label>
<div class="col-md-4">
[% errs.referrer %]
<input id="referrer" name="referrer" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.referrer %]">
</div>
</div>
<hr />
<!-- Radio input-->
<div class="form-group">
[% errs.doi %]
<label class="col-md-4" for="doi">
Danger of infection sample?
</label>
<label class="radio-inline">
<input type="radio" name="doi" id="doi-yes" value="YES"
[% 'checked' IF params.doi.match('YES') %]> YES
</label>
<label class="radio-inline">
<input type="radio" name="doi" id="doi-no" value="NO"
[% 'checked' IF params.doi.match('NO') %]> NO
</label>
</div>
<!-- Radio input-->
<div class="form-group">
[% errs.tb %]
<label class="col-md-4" for="tb">
Microbiological or radiological evidence of TB?
</label>
<label class="radio-inline">
<input type="radio" name="tb" id="tb-yes" value="YES"
[% 'checked' IF params.tb.match('YES') %]> YES
</label>
<label class="radio-inline">
<input type="radio" name="tb" id="tb-no" value="NO"
[% 'checked' IF params.tb.match('NO') %]> NO
</label>
</div>
<!-- Radio input-->
<div class="form-group">
[% errs.previous %]
<label class="col-md-4" for="previous">
Previously investigated by HMDS?
</label>
<label class="radio-inline">
<input type="radio" name="previous" id="previous-yes" value="YES"
[% 'checked' IF params.previous.match('YES') %]> YES
</label>
<label class="radio-inline">
<input type="radio" name="previous" id="previous-no" value="NO"
[% 'checked' IF params.previous.match('NO') %]> NO
</label>
<label class="radio-inline">
<input type="radio" name="previous" id="previous-unknown" value="UNKNOWN"
[% 'checked' IF params.previous.match('UNKNOWN') %]> UNKNOWN
</label>
</div>
<hr />
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="specimen">
Specimen type(s)
</label>
<div class="col-md-4">
[% errs.specimen %]
<input id="specimen" name="specimen" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.specimen %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="sample_ref">
Sample ref
</label>
<div class="col-md-4">
[% errs.sample_ref %]
<input id="sample_ref" name="sample_ref" placeholder="optional field"
class="form-control input-md" type="text"
value="[% params.sample_ref %]">
</div>
</div>
<!-- Text input-->
<!-- // combined with clinical details:
<div class="form-group">
<label class="col-md-2 control-label" for="diagnosis">
Suspected diagnosis
</label>
<div class="col-md-4">
[% errs.diagnosis %]
<input id="diagnosis" name="diagnosis" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.diagnosis %]">
</div>
</div>
-->
<!-- Text input-->
<div class="form-group">
<label class="col-md-3 control-label" for="report_to">
Who should report be returned to?
</label>
<div class="col-md-4">
[% errs.report_to %]
<input id="report_to" name="report_to" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.report_to %]">
</div>
</div>
<div class="form-group">
<label class="col-md-2 control-label" for="clinical_details">
Clinical details & suspected diagnosis<br />[required]
</label>
<div class="col-md-5">
[% errs.clinical_details %]
<textarea id="clinical_details" name="clinical_details"
class="form-control" rows="3">[% params.clinical_details %]</textarea>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-3 control-label" for="treatment">
Chemo/radiotherapy details?
</label>
<div class="col-md-4">
[% errs.treatment %]
<input id="sample_ref" name="treatment" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.treatment %]">
</div>
</div>
<hr />
<div class="form-group">
<label class="col-md-1 control-label" for="hb">Hb</label>
<div class="col-md-1">
[% errs.hb %]
<input type="text" class="form-control" id="hb"
name="hb" placeholder="req'd" value="[% params.hb %]">
</div>
<label class="col-md-1 control-label" for="wbc">WBC</label>
<div class="col-md-1">
[% errs.wbc %]
<input type="text" class="form-control" id="wbc"
name="wbc" placeholder="req'd" value="[% params.wbc %]">
</div>
<label class="col-md-1 control-label" for="wbc">Plts</label>
<div class="col-md-1">
[% errs.plt %]
<input type="text" class="form-control" id="plt"
name="plt" placeholder="req'd" value="[% params.plt %]">
</div>
</div>
<div class="form-group">
<label class="col-md-1 control-label" for="lymphs">Lymphs</label>
<div class="col-md-1">
[% errs.lymphs %]
<input type="text" class="form-control" id="lymphs"
name="lymph" value="[% params.lymph %]">
</div>
<label class="col-md-1 control-label" for="neut">Neut</label>
<div class="col-md-1">
[% errs.neut %]
<input type="text" class="form-control" id="neut"
name="neut" value="[% params.neut %]">
</div>
<label class="col-md-1 control-label" for="other">Other</label>
<div class="col-md-1">
[% errs.other %]
<input type="text" class="form-control" id="other"
name="other" value="[% params.other %]">
</div>
</div>
<hr />
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="taken_by">
Specimen taken by
</label>
<div class="col-md-4">
[% errs.taken_by %]
<input id="taken_by" name="taken_by" placeholder="full name required"
class="form-control input-md" required="" type="text"
value="[% params.taken_by %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="contact">
Contact details
</label>
<div class="col-md-4">
[% errs.contact %]
<input id="contact" name="contact" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.contact %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="datetime">
Date & time of sample
</label>
<div class="col-md-4">
[% errs.datetime %]
<input id="datetime" name="datetime" placeholder="dd/mm/yyyy hh:mm"
class="form-control input-md" required="" type="text"
value="[% params.datetime %]">
</div>
</div>
<!-- Button -->
<div class="col-sm-offset-5 control-group">
<label class="control-label" for="submit"></label>
<div class="controls">
[% IF generate_pdf; btn_type = 'success'; btn_label = 'Submit';
ELSE; btn_type = 'primary'; btn_label = 'Validate'; END %]
<button id="submit" name="submit"
class="btn btn-[% btn_type %]">[% btn_label %]</button>
</div>
</div>
</fieldset>
</div>
</form>
</div>
</div>
<script type="text/javascript">
$('#is_trial').click(function() {
$('#trial-content').slideToggle('fast', function() {
// ok
});
return false;
});
$('#non_trial').click(function() {
$('#non-trial-content').slideToggle('fast', function() {
// ok
});
return false;
});
// nhs number ajax validation:
$('#nhs_number').blur(function() { // alert("Handler for .blur() called.");
var formData = { 'nhs_number' : $('input[name=nhs_number]').val() };
var appMethod = "[% uri_for_nhs_number_validation %]";
$.ajax({
url: appMethod,
data: formData,
type: 'post',
dataType: 'json',
// the response is passed to the function
success: function( json ) { // alert(json.result);
$( "#nhsno_result" ).text(json.result);
},
});
// this also works as a simple 'get' request:
// $.get( appMethod, formData )
// .done( function(data) { $( "#nhsno_result" ).text(data) } );
});
</script>